Our workshop “The Ethics and Practice of Disinvestment: On Knowing What Not to Do in Health and Social Care” took place on the 22nd of May in the Anatomy Museum at King’s College London. The workshop was hosted by the Biotechnology and Society research group. We would like to thank all of our speakers for their absolutely terrific presentations! The talks were followed by a dynamic discussion by an engaged audience. Here we draw out just some of the issues discussed and some initial ideas for further debate and research.
The morning session was dedicated to examining different aspects of the practice of disinvestment, including how such decisions are made, with talks by Jill Manthorpe (Disinvestment in social care), Janet Bouttell (Methods of disinvestment in healthcare), Iestyn Williams (Local decommissioning in the English NHS) and Scott Greer (Change for, with, or against the public: three logics of service redesign across the UK). Themes which emerged included the value placed on different kinds of evidence for different kinds of decision-making, the ‘politics’ as well as practice of different public engagement approaches to these decisions, and the realities of the barriers to and costs of disinvestment as well as any putative savings.
The afternoon session was focused on the ethics of disinvestment, with talks by Mark Sheehan (The ethics of grandfather clauses in healthcare resource allocation), James Wilson (How much ethical weight should be given to reasonable expectations?) and Jim McManus (The ethics of doing least harm). We posed the question: Is there anything ethically distinct about ‘negative’ priority-setting by disinvestment, as opposed to ‘positive’ priority-setting decisions about which treatments and services should be adopted into the health and social care services?
The discussion covered the importance of transparency and better engagement with the nuances of non-equivalence between withdrawing and withholding services, the need for better understanding of, and engagement with, people’s expectations of the NHS and the continuity of care, and the interface between law and ethics when it comes to decommissioning. A key theme emerging was the importance of a close relationship between commissioning and decommissioning, as highlighted by Courtney Davis in her review of the day’s discussions. As she put it, decision-making processes for investment are neither rational nor ethical in the absence of a rational decision-making process for disinvestment. Finally, equity and the politics of disinvestment emerged as a further important theme – there is a concern that much disinvestment is in practice hidden and likely to adversely affect already disadvantaged groups of the population. You can read the reflections of one of our participants, Peter Littlejohns, here.
We convened this symposium following some preliminary discussions within the joint King’s and UCL Social Values and Health group. We felt that the topic of disinvestment was under-researched and that there were ethical considerations which were potentially distinct from those associated with investment or commissioning. The enthusiastic response to our call for participants, and the lively debate on the day, confirmed for us that this is something which does indeed merit further enquiry. Among the areas we are proposing for this are:
- What kind and quantity of evidence should inform disinvestment decisions?
- Are there ‘reasonable expectations’ with respect to ongoing service provision which should inform disinvestment decisions, and are these proprietary to health and social care?
- What is the pertinence of psychological and emotional factors, such as feelings of loss or regret?
- Is there an ethical core to ‘good commissioning’ and should this, by definition, embrace good decommissioning?
- Whose ethics are we talking about? Policy makers, commissioners, providers, end users?
If you are interested in joining this conversation, please contact Gry Wester (email@example.com).
We hope to reconvene and pursue this topic in the not too distant future.